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from its web site at www.dir.ca.gov. These regulations are for the
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§5199. Appendix C1.

The employer
shall ensure that employees who decline to accept a recommended vaccination
offered by the employer sign and date the following statement as required by
subsection (h)(5)(E):

I understand
that due to my occupational exposure to aerosol transmissible diseases, I may
be at risk of acquiring infection with (name
of disease or pathogen). I have been given the opportunity to be vaccinated
against this disease or pathogen at no charge to me. However, I decline this
vaccination at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring ,
a serious disease. If in the future I continue to have occupational exposure to
aerosol transmissible diseases and want to be vaccinated, I can receive the
vaccination at no charge to me.